Dr. W. David Hardy's column from the 3Q 2022 newsletter

Highlights from 2022 Int’l AIDS Conference

By David Hardy, MD
Adjunct Clinical Professor, Keck School of Medicine of USC
Board Member, Foundation for The AIDS Monument

Once every two years (on the even years), the world of HIV activists, researchers, doctors, nurses, persons living with HIV, politicians and most anyone with an interest in this health condition, convenes somewhere in the world to share, discuss, advocate and raise awareness about HIV and the human illnesses it causes.

Having attended all these gatherings since they were first organized in 1985, and not having had a “live” meeting in two years, I jumped at the chance to attend this one and… spend time in beautiful French Canada with friends and colleagues not seen for two years.

Here are some of the scientific highlights I learned at the conference:

HIV Cure

  • Of special note, the fifth person with both HIV (PWH) and cancer was reported to be cured of HIV following a successful allogeneic stem cell transplantation as treatment for a blood cancer (leukemia). This patient (who among those cured is the oldest to date, at age 66 years) was treated at City of Hope in in Los Angeles. Previously, three other men (including Timothy Ray Brown) and one woman with similar results have been reported to be cured over the past 11 years.The treatment wipes out the immune system of the cancer patient and replaces it with immune system of a normal (non-cancerous) person who has HIV-resistant cells.  Like the more recent persons cured of HIV with this medical procedure, much smaller amounts of immune suppressive chemotherapy were successfully used, suggesting that this procedure may work well and be much easier for patients to tolerate.  The “City of Hope” PWH remains cured, off all anti-HIV medications for 14 months.
  • In addition, a 74-year-old woman from Barcelona, who was diagnosed during acute HIV infection 15 years prior (when she was age 59) was treated immediately (i.e., a few weeks) after her diagnosis with a regimen including anti-HIV medications Kaletra (protease inhibitor), and Truvada (TDF/FTC) to suppress her virus along with the experimental immune-enhancing drugs, cyclosporin A, GM-CSF, alpha-interferon and interleukin-2, and underwent intermittent treatment discontinuations. Following the last cessation of her anti-HIV medications, her virus remained suppressed … and has remained so for the last 15 years without antiretroviral therapy.

Global Progress on Stopping New HIV Infections

  • UNAIDS reports that while the number of persons living with HIV across the globe is remaining relatively stable at approximately 38.4 million. However, the number of new persons diagnosed with HIV in 2021 was three times higher than predicted: 1.5 million, instead of 500,000 as predicted.
  • The number of HIV-related deaths decreased by approximately 350,000, from approximately 1 million in 2020 to approximately 650,000 in 2021.  The UN-sponsored organization warned of potential and significant backsliding in the overwhelming progress made over the past 20 years in reducing new HIV infections and blamed the co-occurring COVID-19 pandemic as the origin of this slowdown in progress in eliminating the Global Pandemic of HIV.  Some of the uptick in new HIV infections might be due to the closure of clinics during the COVID-19 pandemic.

Long-acting, Injectable Cabotegravir (Apretude®) as PrEP for HIV

  • More good news about the continued efficacy and durability of once-every-two-month injections of long-acting cabotegravir for HIV PrEP.The continued follow-up of participants in two large, global clinical trials, HPTN 083 (cis-MSM and trans-women) and HPTN 084 (cis-women) after unblinding the study participants one year ago and switching to every-two-months injectable cabotegravir (from daily, oral Truvada due to statistical superior efficacy results), continues to produce superior prevention of new HIV diagnoses, improved tolerability (minimal treatment discontinuations due to injection side effects) and fewer delayed HIV diagnoses by adding routine HIV RNA screening. The ability to de-medicalize PrEP for HIV by having medical providers prescribe, obtain and administer six injections per year has the potential to revolutionize the prevention of HIV around the world.Even more good news: ViiV Healthcare, manufacturer of cabotegravir, committed to share its patent information for cabotegravir with the Global Patent Pool, making it possible for lower-cost (generic) manufactures to make affordable cabotegravir available in resource-limited areas of the world.

Doxy-PEP for STD Prevention in Sexually Active PWH and Persons on PrEP

  • An interesting, but not unexpected, trend of increasing STDs among PWH with undetectable viral loads (amount of HIV in the blood) and persons adherently taking PrEP has been noted recently. Since the use of both of these medications has been documented to prevent over 98% of HIV transmissions, it is not difficult to understand why condom use has plummeted among many persons once at high risk of transmitting HIV … but what about other STDs, like gonorrhea, chlamydia and syphilis?
    • Researchers at UC-San Francisco and U Washington-Seattle conducted a study of such persons, PWH taking antiretroviral therapy and persons adherently taking PrEP for HIV and a recent history of STD(s). The study randomly assigned half of the participants to take one-200mg dose of doxycycline (“Doxy”, an inexpensive, broad-spectrum antibiotic used to treat chlamydia and sometimes syphilis) or nothing within 72 hours of a risky sexual encounter (e.g., condomless, anal sex).  The study was stopped early due to promising results:
      • Overall, an approximately 65% decrease in all STDs among all participants (62% for PWH; 66% for those on PrEP).
      • By STD: 82%-84% decrease in chlamydia; 55%-57% decrease in gonorrhea and 77%-87% decrease in syphilis.
    • All of these comparative risk reductions for post-exposure Doxy were statistically significant for all three STDs in both groups, except for occurrence of syphilis among PWH (number of cases were very small). Side effects were minimal; no study participants left the study due to side effects.As with many antibiotics used to treat gonorrhea, bacterial resistance to Doxy was mildly greater in the PEP-Doxy group compared to the patients who did not take Doxy, thus reducing the longer-term effectiveness of Doxy to prevent gonorrhea.

Monkeypox Updates at IAS 2022 – Montreal

  • In late July-early August 2022, the global Monkeypox (MPX) pandemic was well on its way, with the first cases having been reported in Southern Europe in late April/early May. At the conference, several clinical researchers, epidemiologists and practicing doctors were available to share their abundant knowledge regarding this new outbreak among almost exclusively MSM, approximately 25% to 35% being HIV+.The most outstanding characteristics distinguishing the “new” MPX outbreak from those that have been occurring sporadically in central and western Africa are the following:
    • New MPX lesions are occurring on the genitals, peri-anal and intra-anal areas (proctitis), peri-oral and nasal and rarely in the mucosa of the eyes, as opposed to the “classical” MP lesions which are found on the hands, arms, legs and feet.
    • With the new MPX, pain control due to the severe, exquisitely painful lesions on the penis, anus and rectum are primarily the complications requiring hospitalization and care.
    • Vaccine availability has always been plentiful, BUT, always carefully guarded and rationed by the Department of Defense and Department of Health & Human Services because it is being kept in reserve for a similar disease, smallpox, which is a very close virus and could be used for biologic warfare.  Vaccine roll-out is occurring in most resource-rich parts of the world when a stored or manufacturer source can be found.
    • Treatment with tecovirimat, an authorized, but not FDA-approved medication shown to be beneficial in animals and persons with smallpox, is the only available treatment and had been in highly regulated supply due to the lack of FDA approval but the CDC is now allowing it to be used on a more liberal basis.
    • Very few, if any persons generally die due to MPX.